When breath becomes air – Paul Kalanithi


A book review

This book opens with a stark scene. Dr Paul Kalanithi, a neurosurgeon about to finish his training with flying colours, studies a CT scan. The scan shows a body riddled with cancer. He’s seen hundreds of similar scans in his training. But, he remarks with characteristic economy and understatement, this one is different. It is his own.

After this startling opening, the book looks back to his motivation for becoming a doctor and scientist, inspired by philosophers, poets and writers more than by his cardiologist father. His literary background is clear from his writing style, full of quotes from poems, plays and novels.

With his terminal diagnosis, Kalanithi has time to confront his imminent death. All that he has worked for, for so many years, is snatched away by his ill health, just when it seems within his grasp, but he still wonders whether he should feel grateful for his cancer, as an answer to his constant self-questioning about the meaning of life.

His reaction to his cancer diagnosis is to re-evaluate his priorities in life. He is frustrated by the lack of a precise prognosis. If he had only months to live, he might spend it entirely with his family. If he had a year, he would write a book. If he had ten years, he would keep pursuing his medical career. In the end, he does all these things. He has a baby, conceived by IVF while he is having cancer treatment. He doses up on painkillers, and goes back to finish his residency as a neurosurgeon. And he writes his book, this book, in snatched hours between shifts in the operating theatre, between cancer treatments, in waiting rooms waiting to see his oncologist, and on the chemotherapy unit.

The doctor-patient relationship occupies a lot of his thoughts in the book. As both a patient and a high-flying doctor, he sees things from both sides. A resident he encounters forgets to prescribe one of his cancer drugs, and then refuses to rectify his error because it will mean admitting it to his boss. By contrast, Kalanathi’s oncologist, Emma, gets almost everything right. She is optimistic and practical, and it is she who correctly predicts that he may wish to return to operating after his first cancer treatment. But later, after he has a bad reaction to a chemotherapy treatment, she recognises his need for emotional rather than practical support. Having steadfastly refused to give him any survival statistics, she comes out with the line that he still has five good years. He knows she is lying, but is still grateful.

“There we were, doctor and patient, in a relationship that sometimes carries a magisterial air, and other times, like now, was no more, and no less, than two people huddled together, as one faces the abyss”

That “abyss” is something that we can only learn about from second-hand experiences, as people who have entered it don’t tend to write about it. Doctors, and particularly neurosurgeons, have more second-hand experience of death than most people. Kalanathi finds that his experiences can’t tell him what he wants to know about death itself. But the way he faces his mortality tells us a great deal about life, and how to live it.

Paul and his partner have put off having children until the end of residency – after his cancer diagnosis, knowing that his time is short, they decide to have a baby.

Don’t you think saying goodbye to your child will make your death more painful?” asks Lucy. “Wouldn’t it be great if it did?” he replies.

In an email exchange with a friend, he quips that he’s already “outlived two Brontës, Keats and Stephen Crane. The bad news is that I haven’t written anything.” He sets about fixing this in the time he has left, and his elegant memoir is the result.

The book begins with a jolt, and it ends with a jolt. Abruptly, Kalanithi’s wife takes up the pen, and describes his last few days. He didn’t know how little time he had left, and neither do we as his readers. The loss of his voice, after getting to know and like him over the course of the book, hits home just as hard as the details of his death, laid out with a bare simplicity that perfectly complements the style of the rest of the book.

The shortness of the manuscript is bittersweet – there were certainly many more words he would have liked to have written. But his diagnosis forced him to make every one of them count.




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